US20050159664A1 - Method and apparatus for determining blood flow characteristics in small infants - Google Patents

Abstract

A method of determining the cardiac output of an infant, the method comprising the steps of: (a) measuring the infant's weight; (b) measuring the velocity time integral and stroke distance of blood flowing from the heart of the patient; and (c) utilising the two measurement in step (a) and step (b) to determine the cardiac output of the infant.

Description

FIELD OF THE INVENTION
• The present invention relates to the measurement of cardiac output of infants including pre-term infants and foetuses.
BACKGROUND OF THE INVENTION
• Cardiac output and measurement of cardiac dimensions and haemodynamics are very important indicators in measuring health or detecting disease. The cardiac output, the volume of blood ejected by the heart per minute, is an essential measure of cardiac health.
• Unfortunately, it is often difficult to measure actual cardiac output. Whilst normal fluid flow outputs consist of a flow velocity times a cross section area, it is often difficult to accurately measure the cross sectional area of cardiac vessels. Hence, there is often a large degree of error associated with actual cardiac measurements.
• This is particularly the case with small pre-term infants and, even, foetuses. It would be desirable to be able to measure the cardiac output of such individuals.
SUMMARY OF THE INVENTION
• It is an object of the present invention to provide for an improved or alternative way of measurement cardiac output in infants or the like.
• In accordance with a first aspect of the present invention, there is provided a method of determining the cardiac output of an infant, the method comprising the steps of: (a) measuring the infant's weight; (b) measuring the velocity time integral and stroke distance of blood flowing from the heart of the patient; and (c) utilising the two measurement in step (a) and step (b) to determine the cardiac output of the infant.
• Preferably, the method also includes the step of measuing the correlation between an infant's weight and a corresponding cross sectional area of a cardiac valve for a population of infants and utilising the correlation in step (c) to determine the cardiac output of the infant under study. Preferably, the population can be selected having similar body characteristics to the infant. The method can be utilised to determine the output from either the aortic annulus or the pulmonary annulus.
• Preferably, in one instance, the method can comprise utilising the formula substantially of the form: aortic annular diameter=0.093×weight (kg)+0.25 cm to determine the diameter of the aortic annular and then determining a cross sectional area.
• Preferably, in one instance, the method utilising can comprise utilising the formula substantially of the form: pulmonary annular diameter=0.1×weight (kg)+0.368 to determine the diameter of the pulmonary valve and then determining a cross sectional area.
BRIEF DESCRIPTION OF THE DRAWINGS
• The preferred embodiments of the present invention will now be described with reference to the accompanying drawings in which:
• FIG. 1 is a side perspective view of cardiac monitoring of an adult;
• FIG. 2 illustrates the cardiac monitoring of a neonatal infant;
• FIG. 3 illustrates an example cardiac output;
• FIG. 4 illustrates an analysis of the cardiac output ofFIG. 3;
• FIG. 5 is an example plot of weight to ventricular diameter measurements in infants; and
• FIG. 6 illustrates a flowchart of the steps of the preferred embodiment.
DESCRIPTION OF PREFERRED AND OTHER EMBODIMENTS
• In the preferred embodiment, a new method is provided for measurement of cardiac output in small infants through the utilisation of correlations between weight measurements and integrated transvalvular haemodynamics.
• More particularly, in the preferred embodiment, an infant's weight is utilised to correlate with the cross sectional area of the infant's heart in haemodynamic measurements.
• Recently, in PCT application No. PCT/AU99/00507 and U.S. Pat. No. 6,565,513 entitled “Ultrasonic Cardiac Output Monitor”, the contents of which are hereby incorporated by cross reference, a system was proposed for the continuous wave Doppler direct measurement of transvalvular cardiac flows. Such a system can readily be adapted for use with the preferred embodiment of the present invention to measure flow outputs in infants.
• FIG. 1 illustrates the system described in the aforementioned patent specification wherein an ultrasonic transducer device1 is interconnected to asmall processing computer3 and utilised to monitor blood flows within the heart of patient2.
• The preferred embodiment is particularly directed to young infants such as those born prematurely. Turning now toFIG. 2, there is illustrated the adaptation of the interconnection of the transducer device to aninfant5. In this case, theinfant5 has thetransducer device6 interconnect to the infant's chest so as to provide for Continuous CW ultrasonic monitoring of blood flows.
• Turning toFIG. 3, there is illustrated a typical screen dump from an ultrasonic transducer device being placed in accordance with the teaching of the aforementioned application so as to measure transvalvular flows. InFIG. 4, there is illustrated an analysis of the image ofFIG. 3. With such an output, cardiac output (CO) can be calculated by measurement of the Doppler spectral flow profile of the image ofFIG. 3 to determine the area under the curve or the velocity time integral (vti) or stroke distance—the distance a single red blood cell travels per beat. InFIG. 4, there is illustrated thevti10 which is an “area under the curve” measurement. Further, the heart rate can be determining from the spectral flow profile as the time between peaks e.g.11,12.
• From a measurement of the cross sectional area of the flow (XSA), it is possible to determine the stroke volume (SV) by multiplying the vti so that SV=vti×XSA. SV is the volume of blood ejected by the heart per beat in cm³. CO is a function of SV and heart rate (HR), or the volume per beat times the number of beats per minute, so CO=SV×HR in litres per minute.
• The values for these formulae can be derived from direct measurement of the Doppler flow profile ofFIG. 3 andFIG. 4, with the exception of the flow cross sectional area.
• One possibility for measuring the flow cross-sectional area is to measure the flow diameter using two-dimensional ultrasound, and calculating the XSA using πr². However, normal values for flow diameters obtained are in the order of 1.5 to 2.5 cm for adults and 0.5 cm for term neonates. The resolution of 2D B-Mode ultrasound at 3 Mhz is approximately 1 mm or about 5%. This 5% linear error is the best possible result and, if 95% confidence intervals define sensitivity and equal two standard deviations then the error is approximately 10%. If this error is squared when applied to the πr²formula to determine XSA, the resulting potential error in measurement of the cardiac output is approximately 21%. For neonates lower frequency ultrasound can be used, say 7.5 Mhz with a corresponding increase in spatial resolution, however as the subject diameter is also much smaller, say 0.5 cm in term neonates, the % errors remain similar.
• It will be noted that the error associated with measurement of the Doppler functions alone for application of these haemodynamics equations is less than 5%. The figures for sensitivity of Doppler echo detection of changes in CO are reflected in clinical data.
• In the preferred embodiment, a more accurate method of measuring flow diameter is utilised to provide an increase in the sensitivity of Doppler ultrasound to detection of changes in cardiac output and to thereby improve the clinical usefulness of Doppler flow measurements in infants.
• CO measurements are generally made from Doppler flow profiles across the aortic and pulmonary valves. However, it is also possible to determine CO from the flow across the mitral and trcuspid valves. Measurement of Aortic annular diameter, the two dimensional measure from which the XSA is derived, can generally be performed with reasonable accuracy because the arterial walls are normally perpendicular to insonation in the parasternal long axis position, resulting in high levels of reflected signals. Measurement of the pulmonary annular diameter is more problematic because the vessel walls are often parallel to the ultrasound beam and reflected signal less intense. Of additional importance, the pulmonary artery is the most accessible flow signal for Doppler measurement of CO.
• In the development of the preferred embodiment, a series of studies were conducted of cardiac output of neonates and a correlation determined between the weight of the neonate and the corresponding pulmonary artery annular diameter. In the study, 978 pre-term infants were measured 20 to 30 wks gestational age, 0.420 to 1.690 kg Mean values: Weight=0.986±0.269 kg, PV=0.507±0.059 cm r=0.649, p<0.000 Regression: PV=0.1 wt(kg)+0.368 cm.
• Turing toFIG. 5, there is illustrated a plot of weight versus pulmonary artery annular diameter. Theregression line7 was subsequently derived utilising standard techniques.
• Weight has the additional benefits of being a non-derived unit, is easily measured in infants, and is a commonly patient informed value. Through subsequent analysis, it has been found that the size of the aortic annular diameter can be approximately described by the regression equation as AV=0.093 wt (kg)+0.343 cm. If the heart grows in unison and at a predictable rate, then the pulmonary artery annular diameter will show constant a relationship to the aortic annulus in infants. Hence, the Cardiac Output can be predicted using the aortic annular diameter regression equation and integrated haemodynamics. As input CO equals output CO in the absence of shunt or significant regurgitation, a weight referenced equation to predict the pulmonary artery annular diameter can also be utilised. This can then be applied to standard haemodynamics to determine flow XSA, SV and CO.
• FIG. 6 therefore illustrates a flowchart of the steps involved in the preferred embodiment. Firstly, the weight of the infant is determined21. Next, from the output screen dump of the transducer monitoring device, the heart rate is determined and the velocity time integral is measured23. These parameters are then utilised to calculate the corresponding AV and PV diameter which can then be utilised to calculate the cardiac output.
• In a first initial embodiment a measure for a population of individuals was studied and derived vti values of children and adults found in a sample population to be: Pvti=20.76±3.36 cm and Avti=23.38±3.38 cm, with a vti PV:AV ratio of 1:1.126.
• Whilst the above values were used in calculations, obviously other population samples could be utilised.
• As CO=TO×HR×vti, and pulmonary flow equals systemic (aortic) flow in the absence of a shunt or significant regurgitation, then
  PV XSA×HR×PVvti=AV XSA×HR×AVvti
  As XSA=πr²and AV diameter=(0.093×wt+0.343) and AV radius=(0.093×wt+0.343)/2 then
  (π×(PVd/2)²)×20.76×HR=(π×((0.093×wt+0.343)/2)²)×23.38×HR
  If HR PV=HR AV then
  (π×(PVd/2)²)×20.76=(π×((0.093×wt+0.343)/2)²)×23.38/20.76
  (π×(PVd/2)²)=(π×((0.093×wt+0.343)/2)²)×23.38/20.76
  π×(PVd/2)²=π×((0.093×wt+0.343)/2)²×1.126/π
  (PVd/2)²=((0.093×wt+0.343)/2)²×1.126
  Taking the square root of both sides implies:
  {square root}(PVd/2)²={square root}((0.093×wt+0.343)/2)²×{square root}1.126
  PVd/2=(0.093×wt+0.343)/2×1.06
  PVd/2=(0.093×wt+0.343)×1.06/2
  Then PV Radius=PVd/2=(0.093×wt+0.343)×0.53=0.04929×wt+0.18179 and PV diameter=PVd/2×2=(0.093×wt+0.343)×1.06=0.09858×wt+0.36358
• Therefore both the aortic annular and the pulmonary annular diameter can be determined from simple weight measurements as
  AVd=0.093×wt+0.343
  and
  PVd=0.1×wt+0.363
• As a result, the above formulas can be utilised to calculate the cross-sectional area of the aortic and pulmonary valves. From this calculation, the stroke volumne and CO can also be determined.
• The flow cross sectional area, XSA, in cm²is required to calculate flow volumes and can be determined from direct 2D measurements or calculated from height referenced algorithms. From the above, the XSA algorithms are:
• Aortic
  As AVd=0.093×wt+0.343
• Pulmonary
  PVd=0.1×wt+0.368
  thenPV XSA=π((0.1×wt)+0.368)/2)²
• Stroke Volume
• Stroke voltume, in cm³, is the volume of blood ejected from the heart per beat and is equal to the cross sectional area times the flow vti. Therefore:
  SV AV(adult+children)=π((0.093×wt+0.343)/2)²×AVvti
  SV PV(adult+children)=π((0.1×wt+0.363)/2)²×PVvti
• Cardiac Output
• Cardiac output, in litres per minute, is the volume of blood ejected from the heart per minute and is a function of the cross sectional area, the flow vti and the heart rate.
  CO AV(adult+children)=π((0.093×wt+0.343)/2)²×AVvti×HR
  CO PV(adult+children)=π((0.1×wt+0.363)2)²×PVvti×HR
• By using the above formulas, a determination of important cardiac morphologic dimensions can be made from an infant measurement. This measurement provides an alternative to the currently practiced direct measurement of these dimensions using complex imaging. This can allow for stand alone Doppler intruments to determine accurate measures of cardiac function without the use of complex and expensive imaging devices. This results in an improved method of determining CO in echocardiographic practice.
• The preferred embodiment can also be utilised to determine the cardiac output of unborn babies through the measurement of their cardiac parameters through the wall of the womb and the estimation of the babies weight from measuring the volume of space occupied by the foetus and performing an approximation to the weight of the foetus composition.
• The foregoing describes preferred embodiments of the present invention. Modifications, obvious to those skilled in the art can be made there to without departing from the scope of the invention.

Claims (7)

1. A method of determining the cardiac output of an infant, the method comprising the steps of:

(a) measuring the infant's weight;

(b) measuring the velocity time integral and stroke distance of blood flowing from the heart of the patient; and

(c) utilising the two measurement in step (a) and step (b) to determine the cardiac output of the infant.

2. A method as claimed inclaim 1 further comprising the step of measuring the correlation between an infant's weight and the cross sectional area of a cardiac valve of a population of infants and utilising the correlation in step (c) to determine the cardiac output of the infant.

3. A method as claimed inclaim 2 wherein said population is selected having similar body characteristics to said infant.

4. A method as claimed inclaim 1 wherein said method is utilised to determine the output from either the aortic annular or the pulmonary annular.

5. A method as claimed inclaim 1 wherein said step of utilising comprises utilising the formula substantially of the form:

aortic annular diameter=0.093×weight(kg)+0.25 cm

to determine the diameter of the aortic annular and then determining a cross sectional area.

7. A method as claimed inclaim 1 wherein said step of utilising comprises utilising the formula substantially of the form:

pulmonary annular diameter=0.1×weight(kg)+0.368

to determine the diameter of the pulmonary valve and then determining a cross sectional area.

8. A method as claimed inclaim 1 wherein said method is carried out on an unborn infant utilising an estimate of the infant's weight.

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